75 yr Male with anuria
THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT .
CHEIF COMPLAINTS:
Drowsy ; Anuria ( since 3 days ) ; generalized weakness (since 15 days )
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic 5 years back then he developed lower back pain then treated conservatively . But since 15 days pt developed generalized weaknesses while working in the farm.
Then 3 days back patient developed anuria.
H/O PAST ILLNESS:-
No similar complaints of anuria in the past. But had complaints of generalized weakness since 2 years.
PERSONAL HISTORY:-
Diet:- Mixed
Appetite:- Normal
Bowel movements:- Normal
Bladder:- Decreased urine output
ADICTIONS:-
Alcohol:- 90ml /day since he was 18 years old but stopped 1 year back
Tobacco:-1 pack beedi/day since he was 18 years old but stopped 1 year back.
FAMILY HISTORY:-
Not significant.
TREATMENT HISTORY:-
GENERAL EXAMINATION:-
Patient is examined in a well lit room after obtaining consent
•Patient is conscious, coherent, cooperative.
•Well built and well nourished.
• pallor and edema present.
•Icterus,clubbing, cyanosis, koilonychia are absent
•VITALS
Temp- Afebrile
Bp-150/90 mm hg
PR- 96bpm
RR-24CPM
Spo2- 96% on RA
GRBS : 315 mg/ dl
SYSTEMIC EXAMINATION :
RS- bilateral air entry present
CVS : S1, S2 + no murmurs
P/A- soft and non tender
bowel sounds present
CNS : No focal neurological defeicit
HMF intact
Power in B/L upper and lower limb Is 5
Reflexes are present with B/L plantars and flexors
INVESTIGATIONS:-
PROVISIONAL DIAGNOSIS:-
Acute kidney injury (AKI )
MANAGEMENT:-
Salt restriction < 2g / day
IVF NS 50 ml/ hr
INJ : LASIK 40 mg stat
INJ : PIPTAZ 4.5 g stat
INJ : NEOMOL
O2 supplementation to maintain saturations >85%
Monitor Vitals BP PR TEMP hourly
Strict IO charting
Inform SOS
Comments
Post a Comment